Provider Demographics
NPI:1881683050
Name:GREEN, LINDA T (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LINDA
Middle Name:T
Last Name:GREEN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1591 FURNWALL ST
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48324-3824
Mailing Address - Country:US
Mailing Address - Phone:248-258-8899
Mailing Address - Fax:248-287-4633
Practice Address - Street 1:1591 FURNWALL ST
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48324-3824
Practice Address - Country:US
Practice Address - Phone:248-258-8899
Practice Address - Fax:248-287-4633
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-19
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301005056103TC0700X
MI103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7215028OtherAETNA
MI11277424OtherCAQH
MI298871000OtherMAGELLAN
MI620F348200OtherBCBS
MI119609OtherVALUE OPTIONS
MI7215028OtherAETNA